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Company

Student Medical & Consent Form

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All students under the age of 18 taking part in adventure activities with us, Black Mountain Activities Ltd, must have this form completed as fully as possible by a parent or guardian prior to commencement of the chosen activity(ies). All information given will be treated with the strictest confidence.

School Details

School: Christ College

Lead Contact Sharon Ling

Trip Date: 6 & 8th August 2024

Organised Activities with Black Mountain Adventure
High Level Ropes Course
Climbing & Abseiling Wall
Full Day Gorge Adventure
(for further activity details please see our website)

Participating Student Details

Student Name: *

Date of Birth: *

Home Address: *

Parent / Guardian Telephone Number: *

Gender of child: *

If the above details are correct, please proceed to the next page to provide Medical Details.

Medical Information

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Please declare any medical information that may be relevant for your child / student's activity days. This will help our instructors prepare and/or modify activity sessions to suit all student' needs, ahead of the day. All information given will be treated with the strictest confidence.

1. General Medical Details

Does your child have any medical conditions? *

child have a medical condition?

Yes No

If yes, please give details about condition

Is your child receiving any medication or treatment? *

Are you receiving any medication?

Yes No

If yes, please give details about medication

Does your child suffer from allergies? i.e. stings, bites, penicillin, elastoplasts etc *

Do you have any allergies?

Yes No

If yes, please give details about allergies

Is your child prone to repetitive sports injuries? *

Are you prone to repetitive sports injuries?

Yes No

If yes, please give details about injury

Can your child swim? *

Are you a non-swimmer?

Yes No

If no, please state if confident in water

Are there any conditions/details that you wish to inform us about, not covered above? *

Any additional info that may be relevant?

Yes No

If yes, please give details

For equipment purposes please provide child's approx. Height, Weight & Chest size.*

Height (cms)

Weight (kilos)

Chest (cms)

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Number: *

Doctors Name:

Surgery:

please provide Surgery Name, Town, Postcode

If the above details are correct, please proceed to the final page - Disclaimer.

Disclaimer & Consent

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Whilst we are dedicated to the safety of the clients and endeavour to ensure all activities are operated to a very high standard of safety, there is always an element of unforeseen risk. Anyone allowing their child/student to take part in any activity operated by Black Mountain Activities Ltd does so with this understanding. All activities offered can be physically demanding therefore, the participating child/student should be in reasonably good health & physically fit before taking part. It is always advisable to seek medical advice if you are unsure about their health.

Understanding & Acceptance of Risk

I (the parent/guardian) can confirm that all details given are true and correct and that my child is fit and able to participate in the activities organised *

I (the participant) can confirm that the details given are true & correct:

Yes

I (the parent/guardian) understand that all activities take place in the outdoors where conditions may be wet, slippery and hazardous. I accept that there is an element in unforeseen risk and give consent for my child to take part in the organised activities.*

I (the participant) accept that there is an element of risk in the activities i am undertaking:

Yes

I (the parent/guardian) agree to ensure that my child understands, as far as reasonably possible, that is is important for their safety, that of their peers and as a whole, any rules and instructions given by staff are strictly adhered to at all times. I understand & agree that should an instructor feel my child is jeopardizing the safety of themselves, and/or others, they will be excluded from the activity without refund.*

I agree to comply with the rules and regulations given by staff at all times and should an instructor feel i am jeopardizing the safety of myself and/or others i will be excluded from the activity no refund will be given.

Yes

Consent

I (the parent/guardian) consent to any emergency medical treatment necessary to be given to my child by on-site first aiders or qualified medical respondents in the event of an accident.*

I (the participant) consent to any emergency medical treatment necessary by on-site first aiders or qualified medical respondents in the event of an accident.

Yes

I (the parent/guardian) consent to Black mountain Activities Ltd taking photographs and video as means of promoting the business through displays, presentations, social media and website.

I (the participant) consent to Black mountain Activities Ltd taking photographs and video as means of promoting the business through displays, presentations, social media and website.

Yes No

By submitting this form you are confirming that all details provided are correct and up to date, you confirm that your child is fit and well to participate in activities and consenting to them taking part in the organised activities with us, Black Mountain Activities Ltd. If you should have any queries, please give us a call on 01497 847897.

Student Medical Form (Christ College)

Medical Information

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1. General Medical Details

Emergency Contact Details